Core Care Standards and Care Programme Approach Policy and Procedure

Transcription

1 Cre Care Standards and Care Prgramme Apprach Plicy and Prcedure See als: Assessment and Management f Safety Needs Plicy Assessing Carers needs in mental health services in Derbyshire Minimum standards fr clinical and practice recrds Absence withut Leave Plicy Transfer f yung peple receiving services frm Child and Adlescent Mental Health Services t Adult Mental Health Services Discharge, Transfer/Transitins and Leave Plicy & Prcedure fr peple with mental health difficulties Standards fr Physical Health Care f Peple with Mental Health Prblems and Learning Disabilities Advance Decisins t Refuse Medical Treatment and Advance Statements: plicy regarding patient s treatment wishes expressed in advance Jint Plicy Aftercare fr Detained Patients under Sectin 117 Mental Health Act 1983 Plicy and Prcedures Safeguarding Children Prcedures Derbyshire and Derby Safeguarding Adults Plicies and Prcedures Lcated in the fllwing plicy flder n the Trust Intranet Clinical Plicies Service area Issue date Issue n. Review date Trust wide 06/08/ /07/2017 Ratified by Ratificatin date Respnsibility fr review: Quality Cmmittee 09/07/15 Patient Experience Cmmittee Dcument published n the Trust Intranet under: Clinical Plicies and Prcedures Did yu print this dcument? Please be advised that the Trust discurages retentin f hard cpies f plicies and can nly guarantee that the Plicy n the Trust Intranet site is the mst up-t date versin

2 Checklist fr Cre Care Standards and Care Prgramme Apprach Plicy and Prcedure Name / Title Aim f Plicy Care Prgramme Apprach and Care Standards The plicy aims t utline the standards and prcedures fr the Cre Care Standards (CCS)and the Care Prgramme Apprach (CPA). CCS are the underpinning standards fr all service areas in the Trust. They are based n gd practice care standards acrss mental health, learning disabilities, children s services and substance misuse. Wrking name/title f the plicy/prcedure Brief summary f main aim f the plicy CPA is the underpinning care prcess fr mental health service users with cmplex and serius needs. Spnsr Clare Grainger Name and jb title f persn taking thrugh apprval and signing ff Authr(s) Wendy Slater Jb titles f thse invlved in prducing the dcument Name f plicy being replaced Care Prgramme Apprach and Care Standards Versin N f previus plicy: 1 Name and versin number f the previus plicy this replaces (If applicable) Reasn fr dcument prductin: Cmmissining individual r grup: Replace utdated plicy, changes due t cmmissining alteratins and legislatin, widen t cver the whle Trust Patient Experience Cmmittee Individuals r grups wh have Date: Respnse been cnsulted: Cre Care Standards Prject Bard 2012 Original versin apprved and service representatives Grup Manager DCC Amendments needed General Manager DCHFT Amendments needed Grup Manager Derby City Cuncil Apprved Page 2 f 23

3 Versin cntrl (fr minr amendments) Date Authr Cmment 2012 Wendy Slater Cnsulted and apprved Kathryn Lane Amendments suggested Carle Rbinsn Amendments suggested Phil Taylr Apprved Wendy Slater Amendments made Carlyn Green Final amendments made Page 3 f 23

4 Cre Care Standards and Care Prgramme Apprach Plicy and prcedures Table f cntents 1. Intrductin... 5 Principles... 5 CPA applies t:... 5 Legislative and Plicy backgrund Plicy Statement Values and Principles Assessment... 7 The Assessment... 8 On cmpletin f the assessment... 8 Identifying the need fr CPA Care planning... 9 Crisis and Cntingency Plans Agreeing the care plan Review Planning the review Review cntent After the review C-rdinatin f care Wh is the right persn t crdinate care? Respnsibilities f the Care Crdinatr r lead prfessinal Discharge Crdinating the Discharge The Discharge Plan Carers and Families Supprting Carers and the Triangle f Care Identifying Carers Infrmatin sharing Carers Assessment and supprt Invlvement and Chice Enabling chice and invlvement Keeping yurself and thers safe Psitive Risk Management Page 4 f 23

5 1. Intrductin This intrductin prvides the backgrund and philsphy underpinning the Cre Care Standards (CCS) and Care Prgramme Apprach (CPA). These systems, alngside Self Directed Supprt (SDS), are the fcal pints fr jint wrking arrangements between Health and Scial Services and are the means by which packages f care are prvided t individuals, regardless f setting. The aim f these appraches is t prvide a cmprehensive system f care and delivery. Principles The Cre Care Standards and Care Prgramme Apprach: fcus n the needs f peple using Trust services and their families and carers are based n gd practice are reinfrced by elements f legislatin, circulars, and gvernment plicy are synnymus with the Self Directed Supprt plicies adpted by lcal authrity scial services departments Prmtes recvery and wellbeing, and scial inclusin is underpinned by natinal and lcal standards and evaluatin/audit cmplies with relevant sectins f the Mental Health Act 1983 and its assciated Cde f Practice e.g. Sectin 117 care management has been replaced by self-directed supprt is the framewrk fr care c-rdinatin in mental health care incrprates clinical risk screening, risk assessment, and risk management incrprates and supprts Health Actin Planning and Persn Centred Planning fr peple with a learning disability is a whle systems apprach is delivered and mnitred thrugh jintly agreed plicies, prcedures, and standards CPA applies t: anyne with a mental health prblem, wh has serius and cmplex needs, wh is under the care f secndary mental health services (health and scial care), regardless f setting This plicy shuld be seen in cnjunctin with the guidance n the Cre Care Standards website n Legislative and Plicy backgrund This dcument summarises the respnsibilities in relatin t: The Mental Health Act 1983 (and Cde f Practice) The Care Prgramme Apprach fr peple with a mental illness, referred t specialist psychiatric services. HC(90)23/LASSL(90)11 DH (1990) The NHS and Cmmunity Care Act 1990 Effective Care C-rdinatin in Mental Health Services - Mdernising the Care Prgramme Apprach DH 1999 The Children Act The Carers and Disabled Children Act 2000 and the Carers Equal Opprtunities Act 2004 Valuing Peple DH 2001 Page 5 f 23

6 Refcusing the Care Prgramme Apprach: Plicy and Psitive Practice Guidance DH 2008 The Triangle f Care: Carers included a best practice guide in acute mental health care 2010 Essential Standards f Quality and Safety CQC The Care Act Plicy Statement Peple using the services f the Trust and their families and carers will be supprted in accrdance with the Trust cre care standards. Thse with serius and cmplex mental health prblems will in additin be supprted under the Care Prgramme Apprach (CPA). Fllwing assessment, a system will be in place t identify thse wh need the nging supprt f the CPA. The Cre Care Standards are based n the fllwing standards: Assessment: We will find ut with yu what yur needs are Care planning: Yu will have a clear care plan Review: We will check that things are wrking fr yu C-rdinatin: Yur care will be c-rdinated Discharge/Transfer: We will make sure yur transfer r discharge wrks well Families and Carers: We will wrk with Families and Carers Invlvement and Chice: Yu will be invlved as much as yu want and are able t be Keeping Yurself and Others Safe: We will help yu and thers be as safe as we can 3. Values and Principles Cre Care Standards are underpinned by principles: Quality: We will prvide gd quality services Dignity: We will treat yu with dignity, respect and cmpassin Equality: We will respect yur rights, and make sure yu can access ur services Recvery and wellbeing: We will try t help peple be as well as they can be Cmmunicatin: We will cmmunicate well with everyne Staff: We will emply Staff wh knw what they re ding Envirnment: We will prvide care and supprt in a place that s safe Individual: Yu will be at the centre f yur care and supprt Cmpliments and Cmplaints: Yu can tell us what yu think abut services Safeguarding: We will safeguard children and vulnerable adults Infrmatin: We will keep infrmatin safe and share it when needed, and yu will have the right infrmatin at the right time Partnership: We will wrk tgether with ther rganisatins Values and principles fr mental health services, (regardless f whether service users need CPA r nt). Include: The apprach t individuals care and supprt puts them at the centre and prmtes scial inclusin and recvery. It is respectful building cnfidence in individuals with an understanding f their strengths, gals and aspiratins as well as their needs and difficulties. It recgnises the individual as a persn first and patient/service user secnd. Care assessment and planning views a persn in the rund seeing and supprting them in their individual diverse rles and the needs they have, including: family; parenting; relatinships; husing; emplyment; leisure; educatin; creativity; spirituality; self- Page 6 f 23

7 management and self-nurture; with the aim f ptimising mental and physical health and well-being. Self-care is prmted and supprted wherever pssible. Actin is taken t encurage independence and self determinatin t help peple maintain cntrl ver their wn supprt and care. Carers frm a vital part f the supprt required t aid a persn s recvery. Their wn needs shuld als be recgnised and supprted. Services shuld be rganised and delivered in ways that prmte and c-rdinate helpful and purpseful mental health practice based n fulfilling therapeutic relatinships and partnerships between the peple invlved. These relatinships invlve shared listening, cmmunicating, understanding, clarificatin, and rganisatin f diverse pinin t deliver valued, apprpriate, equitable and crdinated care. The quality f the relatinship between service user and the care crdinatr is ne f the mst imprtant determinants f success. Care planning is underpinned by lng-term engagement, requiring trust, team wrk and cmmitment. It is the daily wrk f mental health services and supprting partner agencies, nt just the planned ccasins where peple meet fr reviews. 4. Assessment Assessment is the way we find ut abut hw smene is and what difficulties they might have, wrk ut what treatment r supprt yu might need and hw we can help. Assessments are carried ut by trained health r scial care prfessinals. We will talk t the persn abut their situatin, any difficulties they have, discuss what they wuld like t happen, and what s imprtant t them. The assessment prcess may vary depending n need and the service referred t. We may smetimes be asked fr an pinin (a cnsultatin) but may nt need r be able t fully assess the needs, in which case we may give guidance. In this situatin, the full assessment standards may nt apply. Assessment will include: The initial assessment will take place when the persn cmes int cntact with the Trust services, having been screened by the service s referral prcedure, and will be undertaken by a wrker wh is qualified t d s. Prir t assessment cnsideratin must be given t the fllwing: Cmmunicatin needs; Validating the referral and ensuring the crrect areas f need will be assessed; Areas f ptential cnflict; Advcacy fr the persn being assessed; and Infrmatin t be sent, such as a service infrmatin leaflet, unless an emergency assessment is required. The persn shuld be reassured abut the cnfidentiality f the assessment, but they shuld knw that the utcme culd be shared with ther members f the care team t ensure that the persn receives the care they need apprpriately and safely. The assessr will explain t the persn why the assessment is being dne, what they can expect t happen, hw they can share in the prcess and wh else is likely t be invlved. The assessr will, wherever pssible, invlve the persn and any family r infrmal carers fully in the initial assessment and in any future assessments taking place, and make the persn aware f any advcacy available, and that they can have supprt frm a friend/relative. Page 7 f 23

8 The assessment will (unless a specialist, crisis, r Mental Health Act assessment) be cmprehensive, and cver all relevant areas including safety The assessment prcess may take mre than ne sessin, meeting r appintment, but supprt, treatment r therapy may start frm the first meeting The assessment shuld be frmulated and recrded using the agreed recrding standards. The Assessment The assessment prcess will include: Listening t and hearing what the persn says Invlving the persn in their assessment as much as they want r are able t, and explaining what happens in a way that makes sense t them Invlving ther peple r agencies if we need specialist advice, assessment r infrmatin Assessing a relevant range f mental and physical health issues, and ther areas relevant t the assessment Taking full accunt f any REGARDS issues (race, equality, gender, age, religin, disability and scial inclusin) in the prcess and cntent f the assessment Identifying any children in cntact, and recrding these. Universal Children s services shuld then be ntified. Identifying risks and safety cncerns Finding ut abut assessments r tests already undertaken, and trying nt t ask the same questins again unless it is necessary Infrmatin frm parents/carers, relatives, r thers (with the persns agreement if are able t cnsent, althugh if there is a significant risk we may have t verride this) Recrding if the persn has an advance statement /directive, and identifying this in the recrd On cmpletin f the assessment Once the assessment is cmplete, we will: Cme up with a frmulatin that summarises and explains what s happened, and helps us t recmmend what might help Recrd infrmatin and share it with the persn, and the referrer (and the family/carer if agreed). Frm an initial actin plan. If there isn t anything we can help with, we ll explain this, and try t signpst the persn t smene wh can. Determine the need fr CPA if the persn is accepted by mental health services. Cmprehensive assessment/s will be cmpleted befre the care planning meeting, r, if the persn is in hspital, n admissin and at agreed intervals befre discharge takes place Identifying the need fr CPA The decisin abut the need fr CPA is taken nce smene has been accepted by mental health services, and is a prfessinal decisin, preferably at an allcatin meeting r review. CPA is nt autmatically applied in hspital r prisn. Any f the fllwing factrs r cmbinatin f factrs can indicate the need fr CPA. Severe mental disrder with high degree f clinical cmplexity Page 8 f 23

9 Current r ptential risks including suicide, self harm, harm t thers, relapse histry, self neglect, nn-cncrdance, vulnerable adult, adult/child prtectin Current r significant histry f severe distress/instability r disengagement Nn-physical c-mrbidity e.g. substance/alchl misuse, learning disability Multiple service prvisin frm different agencies Currently/recently detained under MH Act, r accepted by crisis/hme treatment team Significant reliance n carer/s, r has wn caring respnsibilities Disadvantage r difficulty as a result f: parenting respnsibilities; physical health prblems/disability; unsettled accmmdatin; emplyment issues; significant impairment f functin when mentally ill; ethnicity, sexuality r gender issues In additin, the fllwing key grups will usually be included in CPA. Service users: wh have parenting respnsibilities wh have significant caring respnsibilities with a dual diagnsis (substance misuse) with a histry f vilence r self-harm wh are in unsettled accmmdatin If they are nt, a clear ratinale fr this must be recrded 5. Care planning The cntent f the care plan will always be based n the assessed needs f the persn and interventins shuld be evidence-based wherever pssible. The care plan will be recveryfcused wherever pssible, and always cnsider issues f wellbeing. The detail in the care plan must be adequate fr the purpse, and allw ther wrkers t actin the plan if necessary. The persn whse care plan it is, shuld: have smene else (f their chice) invlved t help them cnsider what is being said r discussed if they wish lead r be actively invlved in putting the plan tgether as much as they are able and want t be ffered a cpy f their care plan, which shuld be in a frmat that is mst useful t them discuss what is in the plan s that everyne invlved understands it and what everyne's rles and respnsibilities are include self-care r actins smetimes referred t as My Plan, r my cntributin t my health and well-being reach a level f agreement n their wn plan. In cases where there is a dispute r disagreement between health prfessinals and the individuals wn plan, this must be explicit and frm part f the plan. When a persn des nt have capacity they shuld be able t talk t smene (an advcate r a named persn) t speak n their behalf abut the plan if they disagree with anything in it have smene wh is respnsible fr making sure the plan happens, and knw hw t cntact them be invlved in a regular review f the plan and their needs, accrding t their capacity the plan shuld be specific n persnal gals and plans, symptm imprvement plans and scial / life gals and plans Page 9 f 23

10 the plan shuld fcus n strengths and wishes as well as being fcused n health imprvement needs Wherever pssible each aspect shuld have a gal and a baseline measure, an achievement, an utcme measure r a rating skill. Fr example. I want t be able t achieve this (any gal). This is hw I will achieve it, this is wh will help me and assist me t achieve it. Wherever pssible have the plan written in the first persn e.g I will The care plan must include: All relevant area including: Why are we ding this? (needs) What are we planning t achieve? (aims and bjectives) Hw are we ging t d it? (actins) Wh will d it? (respnsibilities) Where will it be dne? (times, lcatins) When will it be dne by? (timescales) Hw d we measure that we've dne it? (utcmes) The individual cntributins f the agencies invlved The interventins including: arrangements fr mental and physical health care including medicatin Needs identified in relevant areas such as husing, scial relatinships, finance, emplyment/educatin/training/ccupatin, dmestic supprt, cultural and faith needs, etc. Any needs relating t REGARDS (race and culture, ecnmic disadvantage, gender, age, religin/spirituality, disability r sexuality) Elements f risk and hw the care plan manages these, including; Explicit cntingency arrangements s that the persn r their carer can cntact specialist services if they need t in the event f an absence f a key part f the care plan If families r carers are in dispute, r nt engaged, hw infrmatin and cncerns abut the welfare f the persn they re caring fr will be handled, kept cnfidential and nt shared. This is smetimes described as a Family r named individual plan, r a Chinese wall plan. Where cnsent t discuss care with a named persn is nt given, but receipt f infrmatin t a service t be alerted t wrrying signs, ill health r harm, is permitted, but this cmmunicatin will be a ne way cmmunicatin. A resilience plan smetimes referred t as a crisis plan which sets ut their strengths, what keeps an individual well, preventative strategies, early warning signs f distress r ill health, what the individual and everyne invlved will d if the persn s health deterirates. This shuld als include what t d in an emergency There will be times when an individual des nt agree with their health team n the plan f care. The reasns fr this shuld be explred and, alternative ptins t enable the clinical team and the individual t reach a win win slutin tgether, shuld be cnstantly reviewed and dcumented including reviews f the decisins. This shuld include specifically the differing pints f view and the reasns in the event f a disagreement abut services The date f the next planned review Page 10 f 23

11 Numbers t cntact (the main cntact and any thers, including ut f hurs if needed) The care plan shuld be accessible and be: legible and written in clear and simple language that is easy fr everyne t understand, in accrdance with recrding standards. Persnalised r bespke. The care plan and the individual assessment, frmulatin and patient safety plan are all cnnected and linkages can be clearly seen between these assessment prcesses and the plan. In a frmat apprpriate t the service being prvided Recrded in an accessible way where the persn has: difficulty reading; a visual r sensry impairment; a learning disability; r their first language is nt English Fr service users wh were admitted t hspital with severe mental illness and at medium t high risk f suicide, the care plan shuld include mre intensive prvisin fr the first three mnths after discharge frm in-patient care, and specific fllw-up within tw days after discharge. Where the service user has an advance statement /directive, this shuld be acknwledged in the care plan, and a cpy kept in the clinical recrd Where the service user is at high risk f a restrictive practice e.g. restraint, seclusin, r chemical restraint, then a persnalised care plan (referred t in the Cde f practice as a Behaviural supprt plan, in the trust this is my care plan), shuld identify the persns ptential risks, resilience factrs and a psitive plan t reduce the risk f the use f restrictive practices and shuld include hw an individual wants t be treated shuld this ccur. Where the service user has their wn plan, such as a Wellness Recvery Actin Plan (WRAP), if they chse t share this, it shuld be referenced in the care plan. Resilience / Crisis and Cntingency Plans These shuld be recrded as part f the care plan where safety cncerns have been identified, and shuld be made as accessible as pssible ut f ffice hurs. Cntingency Plans fr absence f part f the care plan: Cntingency planning prevents crises develping by detailing the arrangements t be used where, at shrt ntice, either the care crdinatr is nt available, r part f the care plan cannt be prvided. This culd be, fr example, the sudden absence f the family member wh versees medicatin, r the absence f a staff member thrugh sickness. The cntingency plan shuld include the infrmatin necessary t cntinue implementing the care plan in the interim, e.g. telephne numbers f service prviders and the name and cntact details f substitutes wh have agreed t prvide interim supprt. The Care Crdinatr shuld ensure that a deputy is designated, and recrded n the care plan. Other cntingencies, fr key elements f the care plan which wuld cause the persn t be at risk if they failed, shuld be included. Resilience Crisis plans fr deterirating mental health (see elements f risk abve) Crisis plans shuld set ut the actin t be taken based n previus experience if the user becmes very ill r their mental health is rapidly deterirating. Page 11 f 23

12 Fr service users wh dn t need CPA, where there is n specific risk identified, basic emergency cntact infrmatin meets this requirement, and shuld be given t the service user as sn as they are accepted by services. Fr service users wh need the supprt f CPA, the plan, as a minimum, shuld include the fllwing infrmatin: wh the user is mst respnsive t; hw t cntact that persn; and previus strategies which have been successful in engaging the service user. Agreeing the care plan The care plan shuld be agreed with the service receiver (and their carer/s if apprpriate) wherever pssible. If they d nt accept the suggested plan f care, they shuld nt be discharged frm the service. A review will be called t re-cnsider the situatin, and see if there is a different way t meet their needs. The service user shuld be asked if they wuld like t sign the care plan. If they dn t wish t, r are unable t, the reasn shuld be nted at the end f the care plan. If the persn is n s.117, mre rbust agreements are necessary (see relevant plicies fr guidance) The care plan must be signed by: The persn recrding the plan, such as the Cnsultant/Care C-rdinatr/lead prfessinal. The persn whse care plan it is will be ffered the pprtunity t sign their care plan, unless they chse nt t. Representatives f health and scial services fr peple being discharged frm hspital wh have an entitlement under s.117 f the Mental Health Act. (see s.117 plicy) Cpies f the care plan must be sent t the peple cncerned (after discussin with the persn using the services), including t the persn themselves, s that everyne knws the aims and details f the service being prvided. The G.P. shuld be kept infrmed and invlved, and als be given a cpy f the care plan, r a letter which makes clear hw they shuld respnd if the service user needs additinal help. 6. Review Any plan f care needs t be mnitred and evaluated t see hw it s wrking. It will get ut f date in time, and needs t be reviewed regularly t make sure it s still right. Each persn wh has a care plan will be encuraged t be invlved in a review, which they, r anyne invlved in prviding a service can request. Reviews will be held whenever necessary, but at least nce every year. The reviews will determine the effectiveness and utcme f the persn s care plan in meeting their individual needs, and cnsider any disagreements abut the care plan that may have arisen. Scial Care staff review care under Self Directed Supprt Plicy which is synnymus with the CPA review system and includes sharing infrmatin with service users and all relevant agencies, in accrdance with the Care Act 2014 The purpse f reviews is t cnsider: what further prgress can be made t enhance the persn s and their families/carer s quality f life any prgress the persn has made against agreed bjectives the effectiveness f any treatment the views f the persn, their family/carers and prfessinals hw the persn has respnded t the services being prvided ways in which the needs f the persn may have changed; and as a result Page 12 f 23

13 the extent t which the care plan requires amending. Planning the review The imprtant things t remember are that the review shuld suit the needs f the persn, and that the prcess shuld be agreed with all thse invlved. A review can be held whenever any member f the care team, any infrmal carer/s r the service user feel ne is necessary. If the care team decide that a review is nt necessary, the reasns fr this must be recrded. The review must be planned in advance, with sufficient ntice given, and an agenda, Chair, and minute taker agreed if required. A review must be held within a year frm the date f the last care plan review. It is particularly imprtant t review the implementatin f the care plan within the first mnth f discharge frm hspital. The care team shuld agree which issues will trigger an emergency review. The persn wh wns the plan, the service receiver, shuld be asked t tell their stry f what they want frm their plan, befre the prfessinals lead a discussin f ptins fr that individual t agree t The Care C-rdinatr shuld call an urgent review as sn as pssible if: The service user wishes t withdraw frm their care plan, r part f it The service user discharges themselves frm hspital against medical advice, r threatens t d s There are specific circumstances where infrmal carers r relatives shuld be tld if they are likely t be expsed t vilent behaviur r harm (with r withut cnsent t prtect an individual at risk f harm) this shuld be dcumented in the ntes: the risk; the infrmatin; the assessment and the decisin. There is any majr change in the service user s mental health, persnal r scial circumstances. It is imprtant t remember that a review is a prcess rather than a meeting. Whatever frmat is decided n shuld take int accunt issues f pwer relatinships. A review des nt have any set frmat, and can be anything frm: The prfessinal crdinating the care and the persn sitting tgether and reviewing the care plan, with ther peple cntributing by pst r telephne; r A series f small meetings with the peple cncerned; r A meeting f all the peple cncerned, r Members f the care team frwarding infrmatin t the Care Crdinatr, wh then cnsults the service user. If this is impssible, clear reasns must be given. The prpsed venue must be accessible t thse invited. The persn and their family/carer shuld be cnsulted regarding their level f invlvement in a review meeting. Where a persn/carer wishes nt t attend, this will nt exclude their views being represented at a review. If smene frm the care team is unable t attend a review, the Chair will ask him r her t send a reprt r frward infrmatin. A review shuld nt nrmally be cancelled because f the absence f any participant, if it is pssible t cntinue with a meaningful review. If the persn absent is crucial t the review, it must be re-arranged as sn as pssible with the agreement f all invlved. Page 13 f 23

14 Issues f funding, rganisatin, etc. may be apprpriate fr a separate meeting between the agencies invlved. Review cntent The review shuld allw an pprtunity t cnsider the current care plan, patient safety plan, resilience crisis and cntingency plan, and change them if necessary. The Care C-rdinatr must discuss with the persn and any carers invlved their views f current and future needs and the effectiveness f existing services and treatments being prvided. The Family and r carer s needs and perspective shuld be reviewed at least annually by the agency cmmissined t undertake this. Everyne s pinin shuld be taken int accunt and divergent views recrded. Reviews shuld include: Recent Prgress Physical and Mental Health Treatment, including medicines prescribed and being taken, and any assciated testing. Medicatin will be recnciled at least every 12 mnths t make sure we knw what has been prescribed Safeguarding Children r Vulnerable Adults issues Day time Activities/ccupatin Family/Carer perspectives Safety and risk management Any legal requirements Onging supprt Anything else in the care plan The date f the next planned review The persn shuld cnfirm at the end f the meeting that they agree t the plan and are pting int it. If they d nt agree, this shuld be clearly dcumented. After the review The decisins f the review must be recrded in writing, and recrded n the apprpriate I.T. system/s. Fr peple wh dn t need CPA the clinical r practice ntes may cnstitute the written recrd f the review, as agreed. The persn crdinating the review (such as the Care C-rdinatr) is respnsible fr frwarding cpies f the review recrd and updated care plan t all members f the care team (including the G.P.) the persn (in all cases, except in a public prtectin, preventin f suicide r safeguarding matter) and family/carer (if agreed) 7. C-rdinatin f care Any care prcess is imprved by having a crdinatin rle. Crdinatin f care means that a named wrker will versee care and treatment, keep in clse cntact with the persn, and liaise with thers invlved. The name f the crdinatin functin will vary, and the way c-rdinatin wrks will be different in different services, including: Peple with a mental health prblem will have either a CPA Care C-rdinatr r a lead prfessinal Page 14 f 23

15 Children r yung peple might have a Lead Prfessinal if they need the supprt f the Cmmn Assessment Framewrk Children Peple with a learning disability may have a Care C-rdinatr if they need CPA, r a Health Facilitatr fr Health Actin Planning Wh is the right persn t crdinate care? The prfessinal undertaking the Care Crdinatin rle will be identified as sn as pssible after the assessment, and will be identified in the care plan. The decisin n wh shuld be the Care C-rdinatr shuld take int accunt: the persn s needs and chice; the persn s cultural backgrund; the wrker s experience, training and qualificatins; the cmplexity f the persns needs the wrker s level f input t the care, and relatinship with the persn; the wrker s current caselad size; and their level f authrity. The persn shuld have a chice f Care Crdinatr (particularly where they have had damaging experiences f abuse, r have cultural r religius needs), wherever pssible, taking int accunt resurce availability and assessment f any risks. The prpsed Care Crdinatr must: Be aware f, and have agreed t take n this rle; Be able t refuse t take n the rle f Care Crdinatr fr a persn, e.g. if they d nt have the apprpriate skills; Be in a psitin in the rganisatin which lends itself t carrying ut the rle fr the persn (in terms f grade, r where based); and Familiarise him/herself with past ntes, paper and electrnic recrds befre taking n the rle, r undertaking an assessment. In the event f the care team being unable t agree appintment f a Care C-rdinatr the assessr shuld request that the apprpriate manager intervene s that allcatin is determined within the peratinal pressures f the area. The CPA Care C-rdinatr rle is taken by the persn best placed t versee care planning and resurce allcatin, wh is als: A qualified health care prfessinal an emplyee f a recgnised agency respnsible fr nging wrk with peple wh have mental health prblems. Scial care staff perate under the guidance f the Self Directed Supprt Plicy and within that framewrk als crdinate care. In cases where a high level f scial care need has been identified, and the interventin is prvided by a Trust dctr and a scial care prfessinal, the scial wrker will perate under the Self Directed supprt plicy but will take the lead in crdinating the supprt package. Respnsibilities f the Care Crdinatr r lead prfessinal The persn crdinating the care must: Ensure that a systematic assessment f the persn s health and scial needs is carried ut initially, and again when needed (including an assessment f risk and any specialist assessments) Page 15 f 23

16 Be familiar with past and current recrds abut the persn, bth paper and electrnic Give apprpriate infrmatin, including Trust handbks Ensure that the persn is fully invlved and has chice, and assist them t identify their gals With the persn, cnsider their need fr advcacy, make them aware f any advcacy r self-advcacy schemes, and that they can have a relative, friend r advcate invlved at all stages Ensure that referrals fr Self Directed Supprt are ffered t all thse wh are assessed as having presenting scial care needs. Ensure that a care plan is prduced and sent t all cncerned, including the persn and their G.P. This may be in a letter. Ensure that crisis and cntingency plans are frmulated, updated and circulated as part f the care plan. Fr thse wh dn t need CPA, this may be a cntact card. Identify any infrmal carers prviding supprt, and signpst r refer them t the rganisatins cmmissined t assess their needs. (see the Carers plicy fr mre infrmatin) Ensure that carers and ther agencies are invlved and cnsulted where apprpriate Ensure that the persn understands the care c-rdinatin rle, knws hw t cntact the crdinatr, and whm t cntact in their absence Ensure that the persn is registered with a G.P. and that they are invlved and infrmed as necessary Maintain regular cntact with the persn and mnitr their prgress, whether at hme r in hspital Advise any ther members f the care team f changes in circumstances which might require review r mdificatin f the care plan Organise and ensure that reviews f care take place at least every year. This may be part f a regular meeting/appintment, but the persn shuld be made aware that it is a review, and it must be recrded as such. The CPA Care Crdinatr is als respnsible fr: Explaining t the persn, relatives, and infrmal carers what the CPA prcess is C-rdinating the frmulatin and updating f the care plan/supprt plan, ensuring that all thse invlved understand their respnsibilities and agree t them When rganising a review, making sure that all thse invlved in the persns care are tld abut them, cnsulted, and infrmed f any utcmes. Identifying unmet need and cmmunicating any unreslved issues t managers, thrugh the apprpriate systems Identifying smene t deputise if absent, and passing n the Care C-rdinatr rle effectively t smene else if n lnger able t fulfil it Additinal respnsibilities in specific circumstances, such as if the persn is: entitled t aftercare under s.117 f the Mental Health Act 1983 (see s.117 plicy); r in prisn. Page 16 f 23

17 8. Discharge We want t make sure that if the persn using ur services needs t mve between services, r n lnger needs ur supprt, that the prcess wrks smthly and well. This might be when smene leaves hspital, changes staff r services, r leaves a service. Any transitin, whether discharge r transfer, may have implicatins fr safety, which need t be managed. It s imprtant that the prcess is clear and that everyne understands it. See the Discharge, Transfer/Transitins and Leave Plicy & Prcedure fr peple with mental health difficulties fr mre guidance in this area. Discharges and transfers will: Be planned and prepared fr Invlve the persn in planning them Be c-rdinated by a named persn Include fllw up where relevant Be agreed and c-rdinated with ther rganisatins r services where needed, such as general r specialist inpatient services Include gd liaisn with GP s and Primary Care Services, including infrming them f any significant changes t care, discharges r transfers Recrd any infrmatin that s been transferred, such as summaries, relapse indicatrs r advance directives Include suggestins fr access t ther supprt where apprpriate Have access t supprt frm managers with the prcess Invlve the persn's family/carers, taking int accunt issues f cnfidentiality, Will cnsider the ptential risks t the individual in transitin and be explicit n hw this ptential risk culd be mitigated. Cnsider individuals wh have had a lng standing relatinship with a service r a health prfessinal, issues f relatinships and pssible dependence n the service, and be explicit n hw this ptential risk culd be mitigated. Crdinating the Discharge One persn must c-rdinate the discharge. Wh this is will depend n the type f discharge. It will ften be the persn c-rdinating care, but might be the named nurse, discharge crdinatr, r cnsultant. The scial wrker can als lead this prcess under the Self Directed Supprt Plicy. This persn will be clearly identified, and is respnsible fr making sure that the discharge wrks well and safely. Discussins befre discharge/transfer must include all thse invlved, including: the persn cncerned wrkers prviding care prspective/new prviders where apprpriate, carers. A discharge r transfer is nt cmplete in a secndary service t a secndary service setting until the receiving service has accepted respnsibility and this has been cnfirmed Discussins may take place at a review r ward rund but must have input frm all cncerned. Page 17 f 23

18 The Discharge Plan The discharge plan will include: The reasn fr the discharge r transfer Where frm, where t, when and hw Any fllw-up needed A clear summary f the utcme Wh needs t knw abut the discharge r transfer Any medicines that were used and whether there have been any changes t the prescriptin Any supprt needed if the persn has a caring rle Safety issues must always be taken int accunt in frmulating discharge plans, and Care Crdinatrs shuld liaise with General practitiners when frmulating discharge plans fr service users with a histry f suicide attempt in the previus 12 mnths, and wh have disengaged frm services. The dcuments used t recrd the discharge prcess will vary depending n the circumstances, but culd include any f the fllwing: Ntes, Discharge checklist, Discharge frms, Discharge letter, r any ther apprpriate dcument. The minimum that must be recrded includes: Plan fr the prcess f discharge/transfer Infrmatin abut the discharge frm the service/s including date, time etc. Reasn fr admissin/referral and date f admissin/referral Care prvided and prgress whilst receiving the service(s) Fllw-up plans and thse invlved in them. Infrmatin that must be cmmunicated t thse invlved includes: All infrmatin abut the discharge r transfer including: The plan fr the prcess f discharge/transfer Infrmatin abut the discharge/transfer itself including date, time etc. A cpy f any fllw-up plan, and related infrmatin such as appintment times and dates, where these are, and wh is invlved If the persn is being discharged frm all services, infrmatin n what t d if their health prblems return r becme wrse. 9. Carers and Families Families, parents, and carers are ften a vital part f the life f smene wh needs the services f the Trust, and they can be the peple wh are keeping them well and living in the cmmunity. Where the persn being supprted is a child r yung persn, parents and families are an essential part f the prcess. The Trust values the rle that families and carers play as partners in care, wants t supprt this rle, and wrk with them fr the wellbeing f the persn. All staff will: Identify infrmal carers Treat carers with dignity and cnsideratin Intrduce themselves and any ther wrkers invlved, and explain their rle(s) Cmmunicate with carer/s as far as pssible (taking int accunt the service users views). Prmte Family inclusive practice Page 18 f 23

19 Think Family Recgnise the impact n, and supprt needs f, families affected by thers in their wn right. A Family r Carers care plan/supprt plan which wuld be held in the third party infrmatin sectin f the clinical recrd. Relate family engagement t psitive, sustained recvery utcmes fr individuals and their families. Discuss lcal issues fr bth families accessing supprt, and services prviding supprt. Identify pprtunities t imprve respnses and supprt thrugh develping family inclusive practices t facilitate family recvery. Supprting Carers and the Triangle f Care Infrmal carers have a particularly vital rle, which has been recgnised in the Care Act 2014, enabling carers t access assessment by Scial Care (r cmmissined agencies) n the appearance f need. The Trust is a member f The Triangle f Care: Carers Included scheme, which includes six standards that state that: 1. Carers and the essential rle they play are identified at first cntact r as sn as pssible thereafter. 2. Staff are carer aware and trained in carer engagement strategies. (This includes training r briefing n family inclusive and engagement strategies) 3. Plicy and practice prtcls re: cnfidentiality and sharing infrmatin are in place. (including fr families in relatinship breakdwn) 4. Defined pst(s) respnsible fr carers are in place. (Trust staff wh are respnsible fr families and carers) 5. A carer intrductin t the service and staff is available, with a relevant range f infrmatin acrss the care pathway. (delivered by clinical teams) 6. A range f carer supprt services is available (including signpsting) Identifying Carers All service users will be screened by the initial assessr, the Care C-rdinatr r lead prfessinal t identify thse wh have infrmal carers. This will be recrded bth in the service user s file and n the apprpriate electrnic system. Carers infrmatin shuld be kept in a separate sectin f the file with separate access arrangements. It shuld always be assumed that there may be carers invlved in supprting the service user, until it is clear there are nne. Where there are n carers, this situatin shuld be checked at every review. It is particularly imprtant t recgnise the rle f family and friends wh became carers in a crisis, and may need urgent supprt as well as access t infrmatin. Offer the carer an pprtunity t talk t a member f the service abut hw caring has affected them, and any cncerns they have. Infrmatin sharing Discuss with the service user their views abut invlving the carer(s). The assessr shuld have established if the persn has any bjectin t infrmatin being shared with their carer(s). It is imprtant t agree what the wrker shuld tell the carer if asked. If fr any reasn service users are reluctant t d s, the wrker invlved in the situatin Page 19 f 23

20 shuld always think carefully abut what t d and discuss the implicatins with the individual cncerned, giving reasns fr their prpsed curse f actin. Make sure the carer knws hw t cntact the Care C-rdinatr/lead prfessinal, and wh t cntact ut f ffice hurs, using a cntact card r ther infrmatin medium. Carers Assessment and supprt Give the carer(s) infrmatin abut services fr carers and abut their rights t assessment, as well as general infrmatin abut health cnditins. Refer r signpst carers t relevant rganisatins cmmissined t supprt carers and families. Where the carer is a yung carer (under 18), initial infrmatin will be gathered by the Care C-rdinatr r assessr, which may be fllwed by a Children in Need assessment cmpleted by the Multi Agency Team r Children s Scial Care Take int accunt the impact n the carer f any service prvided fr the cared-fr persn, and the carer s wishes, when planning the care package fr the persn they care fr Carers Champins All services fr adults will identify Carers Champins r Carers Leads wh have a key rle in prmting gd practice fr carers and families See Carers: Wrking with and supprting carers Plicy and Prcedure fr mre infrmatin. 10. Invlvement and Chice Services wrk best when the peple wh use them are invlved in the care prcess. We will always try t make sure that peple are invlved as much as they want and are able t be, and have chices wherever pssible, but chice may smetimes be limited by the services we have been cmmissined t prvide, and by individual s capacity. We will take int accunt peple s diverse needs, particularly arund cmmunicatin and access, respect privacy, dignity and independence We will prtect the rights f ur patients and service users, as well as thse f ther peple, and safeguard them and thers frm harm wherever pssible. We want t supprt peple t make infrmed chices thrugh: taking part in planning care and understanding the care, treatment and supprt chices they have cnsidering chices t prmte and facilitate recvery r ending well care being central t the decisins made arund care having infrmatin t help make infrmed chices and decisins abut things like medicatin being invlved in wrking ut what circumstances make peple s health wrse, and using advance decisins if they want t, t say what they wuld like t happen having family and carers invlved in decisins abut care with chice, cnsent and when apprpriate. using persn-centred care prcesses Page 20 f 23

21 Fr peple wh d nt have the capacity t make decisins in sme areas, we will safeguard their rights under the Mental Capacity Act. All staff will: Treat service users with dignity and cnsideratin Intrduce themselves and any ther wrkers invlved, and explain their rle(s) Make sure that all infrmatin is given in a frm that is clear and understandable Keep appintments made with service users wherever pssible, and nly cancel appintments if unavidable, giving as much ntice as pssible, and re-arranging as sn as feasible. If necessary they will discuss apprpriate cver arrangements with their manager. Prmte mre chices and decisin-making cntrl when capacity is fluctuating r fully returned Enabling chice and invlvement Lead prfessinals and Care Crdinatrs will: Make sure the persn knws that they can invlve an advcate, friend r relative t supprt them Ensure that they are given infrmatin abut the service, treatment, medicatin and care prcess (in an accessible frmat), and shuld talk this thrugh with them Make sure the persn knws wh t cntact at any time Enable peple t be fully invlved in the care prcess wherever pssible, being flexible in their apprach t invlvement Ask the persn t recrd their wn views (r have smene help them with this) Ask the individual t lead, cach and actively invite the persn in agreeing and writing the care plan as much as pssible Request the persn t sign their care plan Give them a cpy f their care plan, review ntes etc Make sure that their needs in respect f gender, age, ethnicity, sexuality, culture, language, and religin taken int accunt in the prvisin f services Make sure that their needs fr cmmunicatin aids / tls and r signs and symbls are requested. 11. Keeping yurself and thers safe We want t make sure peple wh use ur services are as safe as yu can be, and s we will wrk with the persn t find any ptential areas where they dn't feel safe, either with their wn r thers health and wellbeing. This is s that we can help them t manage these situatins, and help them keep safe, as well as family/carers, staff, and the public. We will always cnsider safety fr children, yung peple and vulnerable adults, and try t safeguard them. We will als Think Family. Things we wuld be cncerned abut wuld include: self-harm; self-neglect; suicide; vilence; bullying, dmestic vilence, substance misuse, vulnerability t abuse r neglect, sexual explitatin, mving and handling, infectin cntrl, physical health, and falls. We want t make sure peple feel safe and supprted, including: lking at psitive and balanced risky situatins r behaviurs, and cnsidering the benefits and alternatives; having cnfidence that care staff are using lcal, reginal and natinal best practice; Page 21 f 23

22 feeling supprted thrugh times f emtinal r physical distress; making decisins in partnership with all relevant peple and services; being cnfident that all ur staff are safeguarding the interests f vulnerable peple f all ages; making sure that ur buildings and sites are clean and safe, and that we manage risks such as infectins Including safety plans as part f care planning Finding ways f prmting safety and managing any risks Including plans fr crises and cntingencies where necessary Having a plan fr fllw up if there is disengagement frm the service and there are cncerns abut safety Sharing infrmatin abut safety with the right peple We want peple t experience effective, safe and apprpriate care, treatment and supprt that meets their needs and prtects their rights. Fr mre infrmatin see: Assessment and Management f Safety Needs Plicy Psitive Patient Safety planning and Risk Management Therapeutic r psitive risk-taking can als be used t help peple t develp new skills and pprtunities withut cmprmising their safety. The Trust endrses psitive risk management and will supprt any risk-related decisin if it is: Cnsidered carefully, cllabratively, based upn the best infrmatin available and cnfrming with relevant guidelines/best evidence. All reasnable steps have been taken Recrded in accrdance with the tl/structured prmpt and recrd system in place and that identified safety issues/ risks are reflected in verall treatment/care/safety management plans Cmmunicated All the relevant peple are invlved/infrmed in a timely way. This may nly be n a need t knw basis. Staff must be aware f and cnsider sharing f infrmatin and cnfidentiality prcedures when disclsing infrmatin. Page 22 f 23